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Merging district and practice nurses

Making the headlines recently was the suggestion made by RCGP Wales that the Welsh Government should merge practice nurse and district nurse roles to create generic ‘primary care nurse’ posts closely linked to surgeries.

The RCGP Wales outgoing chair Dr Paul Myres argued that patients currently get ‘fragmented’ care, which lacks continuity, because they have to see both district and practice nurses.

Dr Myres said: “Patients value continuity but they don’t always get it if they use district nurses for one thing and practice nurses for another. If you create a generic role then this nurse could see patients in a practice or could visit them in their homes. There’s a lot of commonality anyway between the practice nurse and district nurse roles now because district nurses often take on chronic disease management.”

Your views

While the idea hasn’t been met with positivity across the board – some practice managers and GPs argue that the roles are completely different – most practice managers we’ve received comments from are in favour.

Many of those in favour of merging the roles echo Dr Myrres’s belief that it would lead to improved continuity and co-ordination. Comments suggest that district nurses will get better support from GPs they know and GPs will get to know the district nurses better.

One practice manager, who said that both of the practice nurses employed in that surgery came from district nursing backgrounds, explained that they would be the first to say that there is so much to learn about practice nursing that does not cross over with district nursing. They added that, in an ideal world, integration would be brilliant as both district and practice nurses would be working in the interest of the patient, and more ‘joined up’ working and better communication would prove invaluable to both practice and community.

Practice and district nurses themselves seem to be in in favour too. One district nurse told us: “I’d love to work more closely with the general practice team as it would provide me with much more continuity and more accountability. Job satisfaction might also improve if I felt more like I was part of a bigger team.”

Forum comments echoed this, stating that district nurses would belong somewhere again giving all the stated benefits to the patients, practices and themselves.

Joined up IT

Integration could bring additional knock-on benefits and an interesting point was made on the Forum by a practice manager. They suggested that IT systems need integrating anyway, so that everyone captures patient clinical data for sharing care. This set-up could help practices to achieve this end.

All about funding

As with all ideas such as this, the thorny topic of funding is at the top of the agenda. One comment received on the Practice Index Forum suggested that district nurses could still be paid by the LHB while others suggest the obvious next step is to integrate district nurses into the practice team, so they are employed by the practice.

How they would be funded is a topic for further discussion and the devil would be in the detail. However, it seems that if district nurses could have a base in a practice, and be fully integrated with the practice nursing team, it might make them feel more valued and part of a worthwhile team, rather than at the beck and call of managers who are always increasing their workload.

What are your views on this suggested merger? Join the conversation in the Practice Index Forum or comment below.

This seems to ignore the fact that there just are not enough nurses community or practice. Merging the intrinsically different will not sort the problem in fact dissatisfaction among the staff could well lead to even more staff leaving and a worsening of the problem.

We are working with practices in our local area on a submission for funding to develop this idea, along with the assistance and support of the local community nursing organisation. Within my own practice we have an Advanced Nurse Practitioner (previously a Community Matron) who does the majority of our acute and CDM home visits. This has revolutionised the way that the GPs work – they come to lunch and meetings on time and are less stressed for example!

The next step is to get social care integrated with the ideas that we have. That will make the biggest difference to the workload in General Practice!

The idea of merging Community Nursing with Practice Nursing is a fine aim but possibly riddled with problems. Fundamentally, the salary scales used by Community Nurses follow the NHS Agenda for Change salary system whereby GP Practices do not always follow the same system but instead use the old Whitley Council grades. It seems to me that if Practice Nurses joined forces with their Community colleagues that an imbalance might occur in the pay and conditions then offered to practice nurses might be ‘better’ than the pay and conditions offered to the rest of the practice staff including Practice Managers. There have already been a number of threads on this site and blogs which show that Practice Staff do not always enjoy the same pay and conditions including annual leave as the rest of the NHS. So in short pay grades might be a significant obstacle…… but then differences in qualifications and training may also prove to be divisive.

HR issues aside – the merger of PNs and DNs is long overdue and the best option would be for practices to be commissioned to provide domiciliary services for their patients. This would mean that the GPs could ensure housebound patients got their flu jabs, had their long term conditions properly monitored and the results input to the Clinical Record and were better linked to their GP in a transparent way for social etc care. PNs seem to me to be better equipped and trained to deal with LTCs and DNs have their strength in palliative care so a merger would give a more rounded skills base that surely must benefit the patients.

Lets` be a bit more radical as well …. what qualifies someone to be either a PN or a DN by working in a hospital for 3 years? Surely the basics are the same – how to take a BP, how to give injections safely etc etc – so why not have two distinct training strands in year 3 ? – those who want their degree in Secondary Care can separate from those who want their degree in Primary Care so when a RGN graduates they can go straight into practice if that is what they chose to do. Think how much time and money would be saved in retraining a Hospital -qualified RGN to do Primary Care work as practices spend now ! PNs take much greater responsibility for independent work in Primary Care and there seem to be few hospital RGNs who know how to manage LTCs so why not formally recognise the division??

I would welcome either the Practice Nurses being based within surgeries or even being employed directly by the practice. The current model is very fragmented and does nothing for continuity of patient care. Although I agree that the roles are different with regard to experience and skills, the concept of integrated care is entirely relevant in todays political and financial climate and should be one that practices embrace. Long Term Conditions are best managed closer to home by a Nurse who would be responsible for the care package, involving the ability to deliver treatment at home when necessary and as the patient’s age and condition deteriorates.